PracticeGuidelines

New AHA Recommendations for Blood Pressure

Measurement
LIZ SMITH
Am Fam Physician. 2005 Oct 1;72(7):1391-1398.

Diagnosisandtreatmentofhypertensiondependonaccuratemeasurementofauscultatorybloodpressure.
Theloweringoftargetbloodpressureforpatientswithdiabetesorrenaldiseasehasmadedetectionof
smalldifferencesmoreimportant.However,bloodpressurereadingisoneofthemostinaccurately
performedmeasurementsinclinicalmedicine.
Truebloodpressureisdefinedastheaverageleveloveraprolongedduration.Thus,inclinicblood
pressuremeasurement,whichgenerallymakesnoallowanceforbeattobeatvariability,canbeapoor
estimationandmayfailtocatchhighbloodpressurethatoccursonlyoutsidetheclinicsetting.In
addition,faultymethodsandthewhitecoateffect(anincreaseinbloodpressurewhenaphysicianis
present)mayleadtomisdiagnosisofhypertensioninnormotensivepatients.
Toincreaseaccuracyofclinicreadings,andinrecognitionofmajorchangesoverthepast10years
(includingtheprohibitionofmercuryinmanycountries),theAmericanHeartAssociation(AHA)has
publishedanewsetofrecommendationsforthemeasurementofbloodpressure.TheAHAscientific
statement,writtenbyPickeringandcolleagues,wasfirstpublishedintheJanuary2005issueof
HypertensionandalsoappearsintheFebruary8,2005,issueofCirculation.Itcanbeaccessedonlineat
http://hyper.ahajournals.org/cgi/content/full/45/1/142.AsummaryoftheAHAscientificstatement
follows.

Classification of Hypertension
Systolicanddiastolicbloodpressuresarepreferredforuseinhypertensionclassification,ratherthan
arterialorpulsepressure.AclassificationofhypertensionandprehypertensionfromtheJointNational
CommitteeonPrevention,Detection,Evaluation,andTreatmentofHighBloodPressureisgiveninTable
1.Prehypertensionhasincreasinghealthrisksandcanprogresstohypertension.
TABLE 1

Classification of Hypertension*

Classification
Normal
Prehypertension
Stage 1 hypertension
Stage 2 hypertension

Blood pressure (mm Hg)

Systolic
119 or lower
120 to 139
140 to 159
160 or higher

Diastolic
79 or lower
80 to 89
90 to 99
100 or higher

*Based on Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the complete
JNC 7 report. Hypertension 2003;42:120652.
Determined by higher blood pressure category based on the average of two or more seated blood pressure
measurements with well-maintained equipment at each of two or more office visits.
Adapted with permission from Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee
of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research
Recommendations for blood pressure measurement in humans and experimental animals. Part 1: blood pressure
measurement in humans. Hypertension 2005;45:14261.

Interpretationofbloodpressuremeasurementsinchildrenmusttakeintoaccountthechildsage,sex,and
height.Hypertensioninchildrenandadolescentsisdefinedassystolicordiastolicpressure,orboth,ator
abovethe95thpercentileofdistribution,usingtablestodeterminenormalandelevatedlevels.

In-Clinic Measurement
Inthestandardclinicprocedure(mercurysphygmomanometerwiththeKorotkoffssoundtechnique),
accuratemeasurementofbloodpressuredependsonthepersondoingthereading,ortheobserver.
Propertraining;useofanaccurate,wellmaintaineddevice;correctselectionandpositioningofthecuff;
appropriatepositioningofthepatient;andrecognitionoffactorsthatmayskewthemeasurementare
critical.Oneofthemostcommonobservererrorsisterminaldigitbias(e.g.,excessiverecordingof
zeroasthelastdigit,orfittingthemeasurementtoaspecificrecognizedthreshold).Guidelinesforin
clinicmeasurementaresummarizedinTable2.
TABLE 2

American Heart Association Guidelines for In-Clinic Blood Pressure Measurement

Recommendation
Patient should be seated comfortably, with back

Comments
Diastolic pressure is higher in the seated

supported, legs uncrossed, and upper arm bared.

position, whereas systolic pressure is higher in

the supine position.
An unsupported back may increase diastolic
pressure; crossing the legs may increase

Patients arm should be supported at heart level.

systolic pressure.
If the upper arm is below the level of the right
atrium, the readings will be too high; if the upper
arm is above heart level, the readings will be too
low.

Recommendation

Comments
If the arm is unsupported and held up by the

patient, pressure will be higher.

Cuff bladder should encircle 80 percent or more of the An undersized cuff increases errors in
patients arm circumference.
Mercury column should be deflated at 2 to3 mm per

measurement.
Deflation rates greater than 2 mm per second

second.

can cause the systolic pressure to appear lower

and the diastolic pressure to appear higher.

The first and last audible sounds should be recorded

as systolic and diastolic pressure, respectively.
Measurements should be given to the nearest 2 mm
Hg.
Neither the patient nor the person taking the

Talking during the procedure may cause

measurement should talk during the procedure.

deviations in the measurement.

Information from Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee of Professional
and Public Education of the American Heart Association Council on High Blood Pressure Research.
Recommendations for blood pressure measurement in humans and experimental animals. Part 1: blood pressure
measurement in humans. Hypertension 2005;45:14261.

Observersshouldbeassessedforphysicalandcognitivecompetencytoperformtheprocedure,including
vision,hearing,andeye/hand/earcoordination.Retrainingofallhealthcareprofessionalsisstrongly
recommendedbytheAHA.Trainingmethodsusingaudiovisualtapestotestandretestaccuracyare
extremelyeffective.Onlineresourcesthatmaybeusefulincludeaguidetoaccuratebloodpressure
measurementathttp://www.igan.ca/id57.htm,andaninstructionalvideofromBMJBooksat
www.abdn.ac.uk/medical/bhs/tutorial/tutorial.htm.
DEVICE

AccordingtotheAHA,mercurysphygmomanometersstillarethepreferreddeviceandshouldbeusedif
availableandproperlymaintained,althoughtheyarebeingremovedfromclinicalpracticefor
environmentalreasons.Thetubingbetweenthedeviceandthecuffshouldbe27.5inches(70cm)ormore
intheofficesetting.Thesystemmustbeairtight,sothetubingandreleasevalveshouldbeinspected
regularly.
Otherdevices,suchasaneroidandhybridsphygmomanometers,maybeusedasasubstituteora
supplement,butthereisnowidelyacceptedreplacement.Mercurysphygmomanometersstillare
necessaryforevaluatingtheaccuracyofotherdevices.
Automatedoscillometricdevicesmaybeusefulforanincreasednumberofreadingsandtoavoid
expensivetraining.Deviceswithlineardeflationratesmaybemoreaccuratethanthosewithstepwise
deflation.Measurementswithautomateddevicestypicallyarelowerthanthosetakenbyaphysician,
perhapsbecauseofthewhitecoateffect;correctpatientpositionandcuffselectionstillarerequired.

Someautomateddeviceshavebeenvalidatedforuseduringpregnancyandmaybeusefulasan
alternativetomercurydevicesinthefuture.Automateddevicesareacceptableinnewbornandyoung
infantsandintheintensivecaresetting,althoughtheirreliabilityisunclear.
PATIENT POSITION

Thepositionofthepatientcanhaveasizableimpactonbloodpressuremeasurements.Forthemost
accuratemeasurement,theAHArecommendsthatthepatientberelaxedandseatedwithlegsuncrossed
andbackandarmsupported.Childrenshouldhavetheirfeetonthefloorratherthandanglingaboveit.If
possible,thepatientshouldbeseatedfiveminutesbeforethereading.Allclothingcoveringthecuff
locationshouldberemoved(rolledupsleeves,iftight,maycreateatourniqueteffectabovethecuff).
Themiddleofthecuffontheupperarmshouldbelevelwiththerightatrium,atthemidpointofthe
sternum.Iftheupperarmisbelowtheleveloftherightatrium,thereadingswillbetoohigh;iftheupper
armisaboveheartlevel,thereadingswillbetoolowInthesupineposition,thearmshouldbesupported
onapillowtoraiseitabovetheleveloftheheart,whichissituatedabouthalfwaybetweenthebedand
thesternum.Inwomenwhoarepregnant,theleftlateralrecumbencypositioncanbeused,with
measurementontheleftarm.
TABLE 3

Recommended Cuff Sizes for Accurate Measurement of Blood Pressure

Patient
Adults (by arm circumference)
22 to 26 cm
27 to 34 cm
35 to 44 cm
45 to 52 cm
Children (by age)*
Newborns and premature infants
Infants
Older children

Recommended cuff size

12 22 cm (small adult)
16 30 cm (adult)
16 36 cm (large adult)
16 42 cm (adult thigh)
4 8 cm
6 12 cm
9 18 cm

*A standard adult cuff, large adult cuff, and thigh cuff should be available for use in measuring a childs leg blood
pressure and for children with larger arms
Information from Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee of Professional
and Public Education of the American Heart Association Council on High Blood Pressure Research.
Recommendations for blood pressure measurement in humans and experimental animals. Part 1: blood pressure
measurement in humans. Hypertension 2005;45:14261.

Thepatientshouldnottalkduringtheprocedure,becausethismaycausedeviationsinthemeasurement.
Otherfactorsthatcanaffectthemeasurementincludeexercise,smoking,alcoholconsumption,muscle
tension,bladderdistension,roomtemperature,andbackgroundnoise.

Inolderpatients,bloodpressureshouldbemeasuredroutinelyinthestandingandseatedpositionsto
screenforposturalhypotension
CUFF SIZE AND PLACEMENT

Themostcommonerrorinbloodpressuremeasurementisuseofinappropriatecuffsize.Considerable
overestimationcanoccurifthecuffistoosmall.ThebladderlengthrecommendedbytheAHAis80
percentofthepatientsarmcircumference,andtheidealwidthisatleast40percent.Errorisminimized
whenthecuffwidthis46percentofthearmcircumference,althoughforlargeadultandthighcuffsthisis
notpractical.Inobesepatients,longer,widercuffsareneededtocompressthebrachialarteryadequately.
Inchildren,cuffbladderwidthshouldbeatleast40percentofthearmcircumferencehalfwaybetween
theolecranonandacromion;thecuffshouldthencover80percentormoreofthearmcircumference.
RecommendedcuffsizesarelistedinTable3.
Forcorrectcuffplacement,themidlineofthecuffbladdershouldbepositionedoverthearterialpulsation
inthepatientsupperarmfollowingpalpationofthebrachialarteryintheantecubitalfossa.Thereshould
bea2to3cmspaceforthestethoscopebetweenthelowerendofthecuffandtheantecubitalfossa,
unlessthiswouldrequireanundersizedcuff.Inpatientswithanarmcircumferencegreaterthan50cm,
thecuffshouldbewrappedaroundtheforearm,supportedatheartlevel,andtheradialpulsefeltatthe
wrist
INFLATION AND DEFLATION

Therateofdeflationinindirectbloodpressuremeasurementsignificantlyimpactsthereading.TheAHA
recommendsthatthecuffbeinflatedtoatleast30mmHgabovethepointatwhichtheradialpulse
disappears.Thecuffshouldthenbedeflatedatarateof2to3mmHgpersecond(orperpulsewhenthe
heartrateisslow).Deflationratesgreaterthan2mmHgpersecondcancausethesystolicpressureto
appearlowerandthediastolicpressuretoappearhigher.Inpregnantwomen,thefifthKorotkoffssound
hasbeenrecommendedasthediastolicmeasurement,althoughthefourthKorotkoffssoundshouldbe
usedwhensoundsareaudiblewiththecuffdeflated.
Forachild,overinflationofthecuffmaycausediscomfort.Onetechniquetoavoidthisistoestimatethe
systolicpressurebyinflatingthecuffwhilepalpatingthepulse,andtheninflatethecuffto30mmHg
abovetheestimatedlevelwhenthepressureisauscultated.
TAKING READINGS

TheAHArecommendsthatatleasttworeadingsbetaken,withaoneminuteintervalbetweenthem,and
theaverageofthemeasurementsrecorded.Thefirstreadinginaseriesisusuallythehighest.Additional
readingsshouldbetakenifthedifferencebetweenthefirsttwoisgreaterthan5mmHg

Atthefirstvisit,bloodpressureshouldbemeasuredinbotharms,whichmaybeusefulforidentifying
coarctationoftheaortaandupperextremityarterialobstruction.Ifthereisaconsistentdifferencein
measurementbetweenthearms,thehighestpressureshouldberecorded.Inchildren,therightarmis
alwayspreferableforconsistencyandcomparisonwithreferencetables.
HYPERTENSION IN CHILDREN

Childrenshouldnotbediagnosedwithhypertensionwithoutconfirmationfromrepeatedvisitsunlessthey
aresymptomaticorhaveprofoundlyelevatedlevels.Themostprecisemeasurementistheaverageof
multiplereadingstakenoverweeksormonths,becausethisallowsforreductionofanxiety.Inchildren,a
differenceofseveralmillimetersofmercuryoftenisfoundbetweenthefourthandfifthKorotkoffs
sounds.Childrenwithrepeatedlyelevatedmeasurementsshouldhavelegbloodpressuremeasuredto
screenforcoarctationoftheaorta.Thiscanbedonebyauscultationoverthepoplitealfossa,withuseofa
thighcufforoversizedarmcuff.Asystolicthighbloodpressurethatismorethan10mmHglowerthan
thesystolicarmpressureiscauseforadditionalcoarctationtesting.

Ambulatory Monitoring
Ambulatorybloodpressuremonitoringisanoninvasive,automatedprocessthatrecordsbloodpressure
overanextendedperiod.Typically,readingsaretakenevery15to30minutesfor24hours,witharound
50to100readingsintotal.Datafromthedevicearedownloadedintosoftwareandcanbetranslatedinto
areport.
IndicationsforambulatorybloodpressuremonitoringarelistedinTable4.Ambulatorymonitoringmay
predictriskformorbiditymoreaccuratelythaninclinicbloodpressurereadings.Itusuallyisusedfor
diagnosisinpatientswithsuspectedwhitecoathypertensionwhoarethoughttobeatlowerriskof
bloodpressurerelatedcomplicationsthanthosewithsustainedhypertensionandrecentlyhasbeen
approvedbytheCentersforMedicareandMedicaidServicesforthispurpose.Anotheruseisthe
identificationofnondippingbloodpressure(i.e.,lessthan10percentreductionfromdaytimeto
nighttimepressure),whichisthoughttoincreaseapatientsriskforcomplications.Increasingevidence
suggeststhatpatientswithhypertensionwhosebloodpressureisloweratnighthavelessriskfor
cardiovascularmorbiditythanthosewhosepressureremainshigh.Ambulatorymeasurementsinolder
patientscanidentifyepisodichypotension.Inaddition,ambulatorymonitoringmaybeusefulinpatients
withrefractoryhypertensionbutlittleorgandamage,thosewithsuspectedautonomicneuropathy,and
thosewhohavewidedifferencesbetweenreadingsfromhomeandclinic,aswellasformonitoring
treatment.

Self-Measurement
Bloodpressuremeasurementstakenonhomemonitors(typicallyoscillometricdevicesthatrecord
brachialarterypressure)may,accordingtoprospectivestudiesfromJapanandFrance,bemoreaccurate

predictorsofmorbiditythanclinicalreadings.Increasingevidencealsosuggestsbettertargetorgan
damagepredictionwithhomereadings,andselfmeasurementinolderpatientsmayaidphysiciansin
antihypertensivemedicationdosingdecisions.Electronichomemonitoringiseasytouse,costeffective,
andmayimprovetherapeuticcompliance.However,onlyfivedevicessofarhavepassedproper
validationtests(alistisavailableonlineathttp://www.dableducational.com).
TABLE 4

Key Indications for Ambulatory Blood Pressure Monitoring

Episodic hypotension
Monitoring treatment
Nondipping blood pressure that does not drop overnight Suspected autonomic neuropathy
Suspected overtreatment with resultant iatrogenic hypotension
Suspected white coat hypertension and discrepant readings between home and clinic

Patientsinterestedinselfmonitoringshouldbeinstructedtositinacomfortablechairforthreetofive
minuteswiththeupperarmatheartlevelbeforetakingameasurement,andshouldberemindednotto
exerciseoreatdirectlybeforethereading.Threereadingsshouldbetakenatintervalsofoneminuteor
longer,andtheaverageofthethreerecorded.Earlymorningandeveningreadingsareespeciallyhelpful.
Normalbloodpressureathomeislowerthanthatintheclinic.Theupperlimitsuggestedbythe
AmericanSocietyofHypertensionis135/85mmHg.Becauseofthepotentialforincorrectreportingto
thephysician,theAHArecommendsthatdeviceswithmemoryorprintoutsbeused.Alowerhomeblood
pressuregoalisrecommendedforpregnantwomen,patientswithdiabetes,andthosewithrenalfailure,
amongothers.